Are you feeling like every time you hire a new nurse and get them trained, another one is on their way out? Even worse, your new nursing hire submits their resignation just a few months after orientation?
To a degree, some nurse turnover is an unavoidable part of the administration of a healthcare facility. A ‘healthy’ turnover rate can reach up to 10% in some industries, but that doesn’t mean that all turnover is positive.
However, an excessive nurse turnover rate is harmful. The good news is that a high turnover rate doesn’t have to be inevitable. Healthcare administrators can take steps to manage and mitigate staff turnover. However, first, let us understand the true costs and the main causes behind nurse turnover.
What is nurse turnover?
Nurse turnover is a metric used to track the rate at which nursing staff leave a healthcare facility over a period of time. This metric reflects the stability of your workforce.
Turnover is expected in any medical facility and can be used to measure the stability of your workforce. A small amount of nurse attrition can be viewed as beneficial, allowing for the infusion of fresh talent with new perspectives, skill sets, and knowledge.
On the opposite side of the coin, a high turnover rate is an important indicator of a systemic problem.
With high turnover comes potential gaps in staffing that can directly and severely harm a facility's financial stability, its operational efficiency, morale of the remaining staff, and the quality of patient care. Ensuring staff retention is a matter that requires attention.
How does nurse turnover affect you?
High turnover has a glaring and immediate impact on the ability of a medical facility to maintain safe staffing levels and conduct business. The financial drain is immediate, and your organization finds itself spending time and money on constant interviewing, recruitment drives, and orientation for new hires.
On top of that, high vacancy rates often force remaining staff members to work more often or longer shifts and take on unbalanced staff-to-patient ratios. The compounded effect of this strain can cause burnout and increase the likelihood of errors and mistakes among the remaining staff, creating a vicious cycle where more nurses may decide to leave.
What can you do?
Knowledge is half the battle; the most effective defense against a high turnover rate is being proactive by developing a strategy of tracking and understanding.
By monitoring why nurses are leaving (the reasons) and calculating how much each departing clinician costs to replace (the financial impacts), administrators can identify retention gaps and then begin implementing a targeted solution as soon as possible.
The impacts of high nurse turnover on healthcare facilities
Let's take the time to look deeper into the effects that high rates of nurse burnout and staff quitting have on medical facilities. The nursing workforce is currently struggling, with an estimated 250,000 nurses having left the field since 2020. There has also been a noted decline in the clinical preparedness of new nurse graduates during this time.
What are some of the reasons for the mass exodus?
1. Increasing staff workload
Research shows the average time it takes to find and hire an experienced registered nurse (RN) is around 83 days. That is a very long time for any medical facility to manage with one or more position vacancies.
Nurse turnover often leads to long periods of time with fewer permanent core staff members. Managers must now scramble to cover open shifts, which increases pressure on the remaining nurses, while adding both financial and administrative burden on the facility.
As the nursing staff struggles to cover added workload, healthcare administrators are often forced to pay for overtime or use expensive temporary nurse staffing agencies. At the end of the day, staffing shortages due to nurse turnover make it harder to meet safe nurse-to-patient staffing ratios and meet your monthly budget.
With that said, being prepared is key to decreasing your risks. Adopting flexible staffing models that allow you to avoid long-term, expensive staffing contracts is just one strategy to get you on the right path.
2. Rising staffing costs
Hiring a new RN to a nursing team can involve a huge investment in both money and time for recruiting, clinician orientation, and on-the-job training. The economics of hiring a new clinician can be staggering.
- The average cost to replace an RN right now is around $61,110.
- For an average hospital, these replacement costs build with each vacancy and can lead to a loss of approximately $4-6 million annually on RN turnover alone.
- The total cost to the U.S. medical industry overall is estimated to reach around $9 billion annually.
That is a seriously high investment for a single replacement. It comes as no surprise that the cost of nurse staffing is a top driver of margin pressures for healthcare systems.
The numbers say it all; the cost of retaining a nurse is far lower than the cost of replacing one. This is why healthcare facilities see such strong returns from investing proactively in nurse retention strategies and shifting their staffing methods from reactive coverage to a long-term, hybrid staffing strategy.
3. Declining patient care and outcomes
When nursing staff numbers are low and morale is in poor condition, the impact is often felt most acutely in patient safety and the quality of care, which ultimately suffer.
A broad-scale review published in 2017 analyzed 35 studies on nurse staffing association with patient outcomes in acute care units and found increased patient mortality and increases in medication errors, ulcers, use of restraints, infections, pneumonia, and interventive procedures.
The data is clear, unbalanced staffing ratios are consistently linked to worse overall patient health outcomes in hospitals, increased medication errors, and patient infections.
4. Higher nurse-to-patient staffing ratios
Fueled at least partly by the long-term nursing shortage that continues to challenge health systems and communities, nurse-to-patient staffing ratios remain popular topics of research and have been linked to patient outcomes by many studies.
In 2022, an in-depth systematic review published findings after analyzing 27 studies assessing nurse staffing and its association with patient outcomes in various healthcare settings. Authors of the review reported that many studies were at risk of bias, making them "likely to underestimate the effect of higher registered nurse staffing." Their findings concluded there is "little room for doubt" that a causal link exists between registered nurse staffing and patient mortality.
Reasons for turnover among nurses
There are multiple reasons and motivations for nurse turnover. Although not all of them are negative—retiring, going back to school to level up licensure, achieving a work-life balance, or moving to another city, for example—the alarmingly high rates the industry is experiencing must be mitigated.
Meeting any goals of turnover reduction and increasing retention demands an understanding of the leading causes in order to strategize how to counter them.
Burnout from heavy workloads
Clinician workload is usually the number 1 reason for nurses leaving. When staffing ratios are too high, stress and burnout are inevitable.
In 2002, just two years before California became the first state to implement—by law—minimum nurse-to-patient staffing ratios, a notable study analyzed hospitals with high nurse-to-patient ratios and found that each additional patient per nurse increased the likelihood of patient death within 30 days by 7%, and an increased likelihood of failure-to-rescue by 7%. Moreover, each additional patient increased nurse burnout by 23% and job dissatisfaction by 15%.
When a nurse is tired and not focused, they are more likely to have mental and emotional exhaustion, which can lead to mistakes, missed care opportunities, and a stronger desire to leave.
Poor onboarding and mentorship
High turnover is commonly seen among new-grad and early-tenure nursing staff. Their lack of experience often leaves them feeling overwhelmed or unprepared. New additions to your healthcare workforce require proper onboarding to start their job with confidence.
To help mitigate this, create a formal and structured mentorship program that pairs new nurses with experienced staff for around 6 months until they are properly onboarded.
Facility and unit culture
The culture of a unit or facility is also a major factor in whether a nurse stays or goes.
Issues such as workplace bullying, rudeness, a lack of managerial support, or the feeling of being undervalued can create a toxic environment that no amount of pay can fix. This can lead to nurses quitting in order to find a more positive work environment.
Compensation and benefits concerns
Compensation, lack of recognition, and under-appreciation are all reasons that seem straightforward and understandable. When a nurse is completely and utterly exhausted emotionally and mentally, financial challenges only worsen the problem.
Lower wages, combined with other factors, can lead to a higher turnover rate. If nurses feel their pay doesn't match their stressful workload, they are more prone to leave. Conducting regular wage audits will ensure that your pay rate is competitive in comparison with other facilities in your region.
9 Strategies to reduce nurse turnover
Burnout is a result of a multitude of factors that tangle together—some within a facility's control and others not. By acknowledging what is within your control as a nurse leader, you can work on ways to reduce nurse turnover.
1. Seek anonymous feedback from nursing staff to understand concerns
It is not enough to tell your nursing staff you are open to feedback. You must create the space for them to do so in a way that they feel safe to be honest.
Establish a method or create opportunities for them to proactively provide anonymous feedback. Look for commonalities and take steps to address concerns or suggestions, which demonstrates that their feedback matters.
2. Provide opportunities for internal career advancement
Check your turnover data and determine how often your nursing staff leaves for better opportunities. Ask the following questions:
- Is there a program in your facility that encourages employee wellness or growth within your organization?
- What are your facility hiring practices when advanced positions open up?
- Do you recruit from within the organization?
- Are there opportunities for advancement available to them so they don't have to leave to grow their careers?
Conducting an audit of your organization’s career progression opportunities may offer insight into why you might lose the most ambitious among your nursing staff.
3. Highlight clinician performance through feedback and recognition programs
Examine your current workplace practices on staff recognition and nurse happiness. Is there a program or system in place that recognizes staff?
Don't stop there. Discuss with your supervisory staff how often they provide feedback to the staff they supervise. How much of it is positive? When it is negative, is it provided with guidance and learning opportunities?
Lead by example, and gather the following feedback from your supervisory or administrative staff:
- Are they feeling appreciated and recognized?
- Do they have the upper-level support and feedback necessary to foster the attitude, work conditions, and culture you want for your nursing staff?
4. Review your scheduling protocols and procedures
Examine your nursing staff's workload and prioritize alleviating their burden. Are your nurses working overtime? Are they being denied vacation leave?
As previously mentioned, recruitment to fill vacancies takes time, so you need affordable yet qualified short-term staffing solutions to fill the gaps when you have vacancies or call-offs.
Staffing coordinators can adopt a few best practices to alleviate workload pressure to reduce staff burnout, including:
- Implement a mandatory no overtime policy
- Adopt an acuity-based staffing system
- Use internal float pools to cover staffing gaps instead of relying on existing unit staff
- Leverage per diem staffing as an affordable alternative to overtime premiums.
5. Address burnout with peer-support programs
Mental and emotional exhaustion are always of concern and should be addressed through formal support programs. Clinicians have to deal with traumatic events and emotional burdens on a daily basis. They are in need of a safe place to process these feelings appropriately.
Try implementing one or more of the following programs to help manage staff stress:
- Schwartz rounds: The creation of structured forums where staff can discuss the emotional challenges of patient care.
- Peer support teams: Trained volunteer nurses who provide immediate and confidential support to fellow colleagues after a tough and emotional shift.
- Debriefing after critical events: Require formal team debriefs after events such as a patient death or a major error occurs.
- Mental health resources: Ensure your clinicians can easily access Employee Assistance Programs (EAPs) or counseling for any emotional trauma that may transpire.
6. Implement shared governance
Give your nurses a voice by ensuring they feel valued for their hard work and input on facility protocols.
Leverage shared governance and create staff councils where bedside nurses can formally participate in an open discussion and help in decisions about clinical practice and the work environment. This ownership not only helps cultivate buy-in for new initiatives, but also gives nursing staff a vested interest in finding creative ways to reduce turnover.
7. Utilize "stay" interviews and anonymous feedback
Exit interviews are good, but by getting proactive and seeking out feedback from your healthcare workforce with “stay” interviews, you can resolve issues that are creating problems before a nurse decides to quit.
By taking the time to have a sit-down with your staff, you will gather useful information on how to retain your most prized resource. Ask them why they stay instead of why they are leaving.
8. Conduct exit interviews to identify common themes
When a nurse leaves, does your HR department conduct an exit interview, or are the reasons learned via gossip and whatever they mention to someone on the way out? Exit interviews can be uncomfortable, but they provide insight into turnover trends.
When one nurse says they are leaving due to underappreciation, you may take it as anecdotal information. However, when—over some time—several leaving nurses mention it, maybe you need to take a look at the work culture.
9. Track the appropriate metrics to assess progress
Fix what needs to be fixed, but don't fix what isn't broken. Tracking the right metrics allows you to understand the true health of your nursing workforce.
- Turnover rate: Track rates for voluntary quits, involuntary terminations, and new-grad/early-tenure staff (leaving within the first year).
- Vacancy rate: Track the percentage of time your facility has budgeted nursing positions open during a calendar year.
- Time-to-fill: Track the number of days it takes to hire a new nurse; understanding the average length of time specific to your facility will help you mitigate the burden on your core staff's workload.
- Overtime hours per FTE: Track the average overtime hours worked by each full-time employee. Spreading overtime hours across your workforce will mitigate burnout risk.
- New-hire retention: Conduct check-ins with new hires at 90/180/365 days to see if your nurse onboarding and unit culture strategies are successful.
- Staff engagement/safety culture survey: Use annual surveys to track and measure how happy your nursing staff are and how safe they feel at their workplace.
Effective patient care starts with your nursing staff
Implementing the suggested retention strategies requires an investment of time and resources. However, can you afford not to take steps to understand and address nursing turnover?
Effective patient care starts with your nursing staff. Provide them with the resources to do their job efficiently and with confidence, which can have positive effects on their morale and your ability to retain their services.
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